Decision-Making Engagement Preferences among Older Adults with CKD.

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Older adults with kidney failure face preference-sensitive decisions regarding dialysis initiation. Despite recommendations, few older patients with kidney failure experience shared decision-making. Clinician uncertainty about the degree to which older patients prefer to engage in decision-making remains a key barrier. Mixed-methods explanatory, longitudinal, sequential design at 4 diverse U.S. centers with patients (English-fluent, aged ≥70 years, CKD stages 4-5, nondialysis) from 2018 to 2020. Patient preferences for engagement in decision-making were assessed using the Control Preference Scale (CPS), reflecting the degree to which patients want to be involved in their decision-making: active (patient prefers to make final decision), collaborative (patient wants to share decision-making with clinician), or passive role (patient wants clinician to make final decision). Semi-structured interviews about engagement and decision-making were conducted in two waves (2019, 2020) with purposively sampled patients and clinicians. Descriptive statistics and ANOVA were used for quantitative analyses; thematic and narrative analyses were used for qualitative data. Among 363 patient-participants, mean age was 78 ± 6 years, 42% were female, and 21% had a high school education or less. CPS responses reflected that patients preferred to engage actively (48%) or collaboratively (43%) versus passively (8%). Preferred roles remained stable at three-month follow-up. Seventy-six participants completed interviews (45 patients, 31 clinicians). Four themes emerged: Control preference roles reflect levels of decisional engagement; Clinicians control information flow, especially about prognosis; Adapting clinical approach to patient preferred roles; and Clinicians' responsiveness to patient preferred role supports patients' satisfaction with shared decision-making. Most older adults with advanced CKD preferred a collaborative or active role in decision-making. Appropriately matched information flow with patient preferences was critical for satisfaction with shared decision-making.